Sverre Bjercke

Impact of Insulin Resistance on Pregnancy Complications and Outcome in Women with Polycystic Ovary Syndrome

The aim of the study was to determine the risk of developing gestational diabetes mellitus (GDM) and pregnancy-induced hypertension (PIH)/pre-eclampsia in a cohort of pregnant women with the polycystic ovary syndrome (PCOS) and known insulin sensitivity status. Pregnancies and neonatal outcome were recorded in a prospective cohort study comprising 29 non-insulin-resistant PCOS women, 23 insulin-resistant PCOS women and a control group of 355 women who had conceived after assisted reproduction. Hypertension, pre-eclampsia and GDM were recorded as well as pregnancy duration, method of delivery and birth weight. The frequency of hypertension was significantly elevated in PCOS women (11.5%) compared to controls (0.3%), p < 0.01. However, the frequency of pre-eclampsia was significantly elevated only in the insulin resistant PCOS women (13.5%) compared to controls (7.0%), p < 0.02. GDM was significantly more frequent in PCOS women (7.7%) than controls (0.6%), p < 0.01. Insulin resistance prior to pregnancy, determined by continuous infusion of glucose with model assessment (CIGMA) test, did not further increase the frequency of GDM. Newborns from PCOS pregnancies were significantly more often delivered by Caesarean section than controls (40.3 vs. 27.3%, p < 0.05) and transferred to neonatal intensive care unit more often than controls (19.2 vs. 9.0%, p < 0.01). Thus we show that the frequencies of pre-eclampsia and GDM are increased in PCOS pregnancies.

In vitro fertilization is a successful treatment in endometriosis-associated infertility

OBJECTIVE To assess success rates of IVF and intracytoplasmic sperm injection in women with various stages of endometriosis. DESIGN Retrospective cohort study. SETTING Reproductive medicine unit in a university hospital. PATIENT(S) Infertile women (n = 2,245) with various stages of endometriosis or tubal factor infertility. INTERVENTION(S) IVF or intracytoplasmic sperm injection. MAIN OUTCOME MEASURE(S) Dose of FSH, number of oocytes retrieved, fertilization rate, implantation rate, pregnancy rate (PR), live birth/ongoing PR. RESULT(S) Women with endometriosis had similar pregnancy and live birth/ongoing PR as did women with tubal factor infertility, but the American Society for Reproductive Medicine (ASRM) stage I and II endometriosis patients had a lower fertilization rate, and stage III and IV patients required more FSH and had fewer oocytes retrieved. Splitting the stage III and IV groups into patients with and without endometriomas showed that the endometrioma group required more FSH and had a significantly lower pregnancy and live birth/ongoing PR. CONCLUSION(S) With the exception of patients with endometrioma, infertile women with various stages of endometriosis have the same success rates with IVF and intracytoplasmic sperm injection as patients with tubal factor. This contrasts with the systematic review on which the European Society of Human Reproduction and Embryology bases its recommendations.

Intracytoplasmic sperm injection (ICSI) in unexplained and stage I endometriosis-associated infertility after fertilization failure with in vitro fertilization (IVF)

AbstractPurpose: To investigate possible differences between unexplained and stage I endometriosis-associated infertility in ICSI cycles conducted after low fertilization (<20%) in preceding IVF cycles with normal semen parameters. Methods: Retrospective cohort study consisting of patients with unexplained (n=48) and stage I endometriosis-associated infertility (n=43) with a minimum of one IVF cycle with <20% fertilized oocytes and normal semen quality, treated with ICSI from January 1997 to January 2006. Age matched male factor infertility patients (n=91) were used as controls. Results: Diploid fertilization rate was significantly lower in the stage I endometriosis-associated infertility group compared to the unexplained infertility group. Score of the transferred embryos, implantation rate, pregnancy rate and outcome were similar in the two groups. Conclusions: ICSI appears to be an efficient treatment option after fertilization failure with IVF in unexplained and stage I endometriosis-associated infertility.

Comparison Between Two hCG-to-Oocyte Aspiration Intervals on the Outcome of In Vitro Fertilization

AbstractPurpose: To determine whether there was any difference inthe outcome of in vitro fertilization when retrieval of oocyteswas done 34 hr (group A) or 38 hr (group B) after hCGinjection. Methods: A total of 170 patients with tubal failure wererandomized into either group A (83 patients) or group B(87 patients). They underwent in vitro fertilization accordingto described protocols and were compared with regard tothe frequency of spontaneous ovulation, number of oocytesretrieved, oocyte cumulus complex quality, embryo quality,and implantation and pregnancy rates. Results: There was no significant difference for any of theparameters tested for in group A and group B. Conclusions: HCG can be administered at any time withinthe time interval of 34 to 38 hr before retrieval of oocyteswithout affecting the results of in vitro fertilization.

Clinical outcome following stimulation with highly purified hMG or recombinant FSH in patients undergoing their first treatment cycle of IVF or ICSI

Objective. To test whether the clinical efficiency of recombinant FSH (rFSH) and highly purified human menotrophin (hMG) differs in terms of pregnancy and live birth rates during the first treatment cycle of IVF or ICSI. Design. Prospective cohort study. Setting. Department of Gynecology and Obstetrics, Rikshospitalet, Oslo University Hospital. Study population. Records of 1,136 infertile couples undergoing their first IVF (n = 682) or ICSI (n = 454) treatments were reviewed. The effect of hMG and rFSH was analyzed for the IVF and ICSI groups separately. Methods. Patients received long term down‐regulation with GnRH agonist and controlled ovarian hyperstimulation with hMG or rFSH. Oocytes were fertilized by IVF or ICSI. Embryos were transferred on Day 2. Main outcome measures. Primary outcome measures were pregnancy and live birth rates, secondary outcome measures were duration of treatment, doses of hMG or rFSH applied, number of oocytes retrieved and the number and quality of embryos obtained. Results. Similar pregnancy and live birth rates were observed with hMG and rFSH. Compared to hMG, treatment cycles with rFSH were characterized by significantly shorter stimulation, lower gonadotrophin consumption, and increased number of oocytes and embryos. Conclusion. We conclude that rFSH and hMG are equivalent in terms of clinical efficacy.

The impact of insulin resistance on the outcome of laparoscopic ovarian electrocautery in infertile women with the polycystic ovary syndrome.

In this study we assessed how insulin resistance affects pregnancy rates in infertile women with the polycystic ovary syndrome (PCOS) treated with laparoscopic ovarian electrocautery. Sixty-four PCOS women were included in the study in a consecutive fashion. Following the CIGMA (continuous infusion of glucose with model assessment) test, 28 women were classified as insulin resistant and 36 women as non-insulin resistant. After the ovarian electrocautery patients were observed for 12-18 months. If pregnancy did not ensue, they were referred for one or more cycles of in vitro fertilization (IVF). Following ovarian electrocautery the non-insulin-resistant women more frequently achieved a regular menstrual cycle and ovulation than the insulin-resistant PCOS women. Consequently 18 (50%) of the non-insulin-resistant PCOS women achieved a pregnancy versus only five (18%) of women in the insulin-resistant PCOS group. Following treatment with both ovarian electrocautery and IVF, 27 (75%) of the non-insulin resistant PCOS women achieved a successful pregnancy, while 13 (46%) of the insulin-resistant PCOS group achieved this. In conclusion, insulin resistance may be an important marker of a poor outcome of treatment in PCOS infertility. Further studies are needed to evaluate the possible effect of treatment alternatives to alleviate the unfavorable influences of insulin resistance and hyperinsulinemia on ovulation induction in PCOS women.

Cycle Characteristics of Day 3 Embryo Transfers with 4-Cell Embryos Only

AbstractPurpose: Patient and cycle characteristics of day 3 transfers with developmentally lagging 4-cell embryos only were analyzed and related to the outcome of a live birth. Methods: Day 3 transfers with either 4-cell embryos only (study group; n = 138) or 8-cell embryos only (control group; n = 282) were compared retrospectively. Results: The total dose of FSH per treatment was higher, while the number of oocytes, zygotes, and transferred embryos was lower in the study group cycles compared to controls. The implantation, pregnancy, and live birth rates were dramatically lower in the study group compared to the control group. In the study group, the few cycles resulting in a live birth were characterized by a normal ovarian response to stimulation, similar to that of control group cycles with- or without a live birth. Conclusions: In cycles characterized by intensive ovarian stimulation, but poor response, the chance for a live birth is extremely low after day 3 transfer of 4-cell embryos.

Ovulation induction in polycystic ovary syndrome

The objective of this narrative review was to suggest a rational order of treatment choices in anovulatory women with polycystic ovary syndrome (PCOS), for whom a multitude of treatment options exist. In obese/overweight women with PCOS the importance of weight reduction should be stressed. Inositol, a dietary supplement with a documented effect on ovulation and without adverse effects in the doses recommended, may be suggested. Additional first‐line medical alternatives include insulin sensitizers, selective estrogen receptor modulators, and aromatase inhibitors. Of these, the aromatase inhibitor letrozole and the combination of clomiphene citrate and metformin have the highest rates of ovulation and live birth. Second‐line treatments are ovarian electrocautery and low‐dose follicle‐stimulating hormone stimulation. Controlled ovarian stimulation with in vitro fertilization, should be considered the last option as it carries a significant risk of ovarian hyperstimulation syndrome in patients with PCOS.